Diabetic retinopathy remains the leading cause of blindness among working-age U.S. adults despite the fact that major NEI clinical trials show that early detection and treatment reduce the risk of severe vision loss by 90%. Adherence with yearly diabetic retinopathy screening guidelines in the U.S has stagnated at 50%. Ocular telemedicine (i.e. tele-ophthalmology) can be highly effective for increasing diabetic retinopathy screening rates, but there is very limited utilization of these programs in multi-payer health systems, which constitute the majority of U.S. healthcare systems. Significant barriers exist to the successful application of tele-ophthalmology, but these barriers are poorly understood. Dr. Liu's K23 research plan aims to (1) identify primary care provider and patient-level barriers and facilitators to tele-ophthalmology screening for diabetic retinopathy in a rural, multi-payer healt system, (2) develop an implementation package to overcome those barriers at a single primary care site, and (3) pilot-test the impact of this implementation package on diabetic retinopathy screening rates at multiple primary care clinics. She hypothesizes that this implementation package, structured upon well-established frameworks for increasing adherence with diabetes care guidelines and healthcare process improvement, will successfully integrate tele-ophthalmology into the existing healthcare system, and will both achieve and maintain increased diabetic retinopathy screening rates. Dr. Liu's long-term career goal is to reduce vision loss in underserved communities by expanding access to eye care through ocular telemedicine. Her proposed mentored research and training would provide the further skills needed to become an independent investigator in ophthalmic health services delivery with additional expertise in the emerging field of dissemination and implementation science. She will access a wealth of resources through the University of Wisconsin, including accomplished NIH-funded mentors and collaborators in the multidisciplinary fields of telemedicine, epidemiology, mixed methods (i.e. qualitative and quantitative), dissemination and implementation, industrial/systems engineering, and health services research. This K23 proposal directly responds to multiple elements of the National Eye Institute's (NEI) Health Disparities Strategic Plan and National Plan for Eye and Vision Research (NPEVR). These include areas of emphasis in health services research, diabetic retinopathy, and expanding access to rural, underserved populations. The NEI Health Disparities Strategic Plan states that telemedicine has great potential to reduce access disparities and the NPEVR calls to expand efforts in telemedicine to manage diabetic retinopathy...for rural and/or underserved populations. By understanding how to effectively integrate and utilize ocular telemedicine in multi-payer health systems, Dr. Liu's research will facilitate the effective translation of telemedicine technology ino improved diabetic retinopathy screening rates in the community. Building from this work, she plans to develop future telemedicine screening and management protocols for other major causes of visual disability such as uncorrected refractive error, macular degeneration, and glaucoma. Advancements in ocular telemedicine have the potential to provide unparalleled access to eye care for millions of Americans and the effective translation of these technologies will be critical both for addressing health disparities as well as to meet the growing needs of our aging population.